RN Nurse Medical Management Specialist

3 weeks ago


St Louis, Missouri, United States Elevance Health Full time
Job Summary

We are seeking a highly skilled RN Nurse Medical Management I to join our team at Elevance Health. As a key member of our medical management team, you will play a critical role in promoting quality member outcomes, optimizing member benefits, and promoting effective use of resources.

Key Responsibilities
  • Collaborate with healthcare providers and members to ensure medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting.
  • Work with medical directors to interpret appropriateness of care and accurate claims payment, and may also manage appeals for services denied.
  • Conduct pre-certification, concurrent, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
  • Collaborate with providers to assess members' needs for early identification of and proactive planning for discharge planning, and facilitate member care transition through the healthcare continuum.
Requirements
  • Current unrestricted RN license from the state in which you reside and a minimum of 2 years acute care clinical experience.
  • Ability to interpret and apply member contracts, member benefits, and managed care products, and strong leadership skills.
  • Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs, medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources.

Elevance Health operates in a Hybrid Workforce Strategy, and candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19.



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